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APPLICATION FOR PERMITS lit1 SAN JOAQUIN LOC_ AL'HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in Triplicate) y J Application is hereby made to theSanJoaquin Local Health District for a permit to construct and/or install the work herein described. This application is i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rgles and Regulations of the San Joaquin Local Health District. 1 Job Address _ �EL� (�CIL� City .S TA� Lot Size i' }' PM Owner's Name 5- T © Address CN_-e— Phone '"`l+ Y A Contractor .t'r�r, Address c3 icerise 4o.Z 3 Phon 1.— &CD TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 14 E` ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA .r CONSTRUCTION.SPECIFICATIONS ) ❑ Industrial ❑ Open Bottom ElManteca , Dia. of Well Excavation Dia. of Well Casing S� r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ``h Type of Casing 1 Specifications \ ❑ Public ❑ Other ❑ Delta 't0 Depth of Grout Seal i + Type of Grout ❑ Irrigation a --Approx. Depth ❑ Eastern Surf_ace Seal Installed by Repair Work Done 13 Type of Pump H.P. 4 State Work Done Well Destruction ❑ Well Diameter Sealing Material (top-50') ; Depth Filler Material (Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms r V Character of soil to a depth of 3 feet: } Water table depth SEPTIC TANK Type/Mfg Capacity No.`-Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line rt, _ L m . - LEACHING LINE -❑ .No. & Length of lines r d Total length/size . FILTER BED ❑ Distance to nearest: Well`° Foundation Property Line Q' a # f SEEPAGE PITS ❑;,Depth t Size. � _ Number SUMPS :O 'Distance to nearest' Well Foundation Property Line DISPOSAL PONDS ❑. 71. r I hereby certify that I have-prepared this application and that,the work will be done in accordance with San Joaquin county ordinances,state laws, and 1rules and regulations of the San Joaquin Local Health District. i *Home owner or'licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies'the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- ! tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. E [.��► Signed Title: ✓—f;--- �F _ Date: T�� Z FOR DEPARTMENT USE ONLY- "p Application Accepted by Date Area Pit or Grout Inspection by Date Final inspection by + { �; Date Additional Comments: r # ,.r ❑ Stk 466-6781 ❑ Lodi 369-3621 U13 Manteca 823-7104 ❑ Tracy ' Applicant- Return all copies toc Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED . CASH RECEIVED BY DATE PERMIT'NO. SEH13-241REV,1/s 51 0-0 EH 1426 v